The Latest Salvo From the Dartmouth Atlas Project

Researchers at the Dartmouth Atlas of Health Care have released a new report which examines variation in care at academic medical centers and which is partly designed to influence medical students who may be looking at residencies at those schools.  (Dartmouth Report)   The authors theory seems to be that medical students will pick up the practice style of the medical center where they do their residency and they should consider that practice style before selecting a residency program.  The centers studied are all relatively large, prestigious ones that presumably do have a significant effect on care in a wide geographic area.  The report looks at end-of-life care, preference-sensitive care and patient care quality at 23 academic medical centers.  Using a hospital care intensity index, the authors find a three-fold variation in end-of-life care.  The authors then suggest that something must be wrong with this much variation, when these centers should be leaders in evidence-based medicine.  This is illogical, it more likely reflects the fact that there is no clear standard of care for most medicine so you are going to see a lot of variation.  They also use graphs on supply and care intensity to support their argument but these graphs apply to all 306 hospital referral regions, not to the academic medical centers.  Very weak.

Looking further at end-of-life care they suggest the intensity in some centers may be contrary to patient preference.  But if you don’t specifically survey that, how can you come to any conclusions?  They also note high rates of variation in common surgical procedures, at least using actual data on these centers’ HRRs for this analysis.  The researchers next detour off on a long explication regarding uncertainty in right rates and having to reflect patient preference through shared decision-making, but again, there is no data supporting any survey of what patients want versus what they get. Looking at quality, generally these centers have high scores and high patient experience ratings.  Yet the authors use this to detour off to one of their favorite general theses, that higher intensity of care is not always correlated with quality.  Here it is not clear that they actually looked a the academic medical centers in the data they provided, nor is it clear they adjusted for illness severity.  People who are sicker need more care, are more likely to have worse outcomes and therefore are not as likely to be satisfied.  All in all, a very weak piece of advocacy rather than research.